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Cook LB, Gunasingha MRMKD, Dishman LS, Bartel LM, Bradley CM, Gosztyla LC. Referral practices are associated with a delay in treatment of symptomatic cholelithiasis and cholecystitis. Am J Surg 2024; 227:96-99. [PMID: 37806893 DOI: 10.1016/j.amjsurg.2023.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The project was performed to determine if referrals to non-surgical providers after an initial presentation of symptomatic cholelithiasis are associated with a delay in surgical management. METHODS A single institution chart review of all adult patients who underwent a cholecystectomy from 2015 to 2019 was completed. Quantitative data was analyzed using independent t-tests. RESULTS Of 574 reviewed, 482 patients met criteria. Following initial presentation, 295 (61.2%) received a referral to surgery and 187 (38.8%) received follow up with a non-surgical provider. Those in the latter group had a significantly longer time from initial symptom presentation to surgical evaluation (65.7 days vs. 10.3 days, p < 0.001) and cholecystectomy (102.0 days vs 39.1 days, p < 0.001) when compared to the surgery referral group. CONCLUSIONS This study demonstrated that cholecystectomy was significantly delayed for patients who had been referred to non-surgical providers after initial presentation, prolonging symptoms and increasing use of healthcare resources.
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Affiliation(s)
- Lt Brittany Cook
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Ave, Bethesda, MD, 20814, USA; Department of Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20814, USA.
| | - Maj Rathnayaka M K D Gunasingha
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Ave, Bethesda, MD, 20814, USA; Department of Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20814, USA
| | - Lt Sydney Dishman
- Department of Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20814, USA; Naval Medical Center Portsmouth Department of Aviation Medicine, Carrier Air Wing Three, USA; En Route and Critical Care Research Department, Naval Medical Research Center, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Lt Megan Bartel
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Ave, Bethesda, MD, 20814, USA; Department of Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20814, USA
| | - Cdr Matthew Bradley
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Ave, Bethesda, MD, 20814, USA; Department of Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20814, USA
| | - Lcdr Carolyn Gosztyla
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Ave, Bethesda, MD, 20814, USA; Department of Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20814, USA; En Route and Critical Care Research Department, Naval Medical Research Center, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
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Thunnissen FM, Baars C, Arts R, Latenstein CSS, Drenth JPH, van Laarhoven CJHM, Lantinga MA, de Reuver PR. Persistent and new-onset symptoms after cholecystectomy in patients with uncomplicated symptomatic cholecystolithiasis: A post hoc analysis of 2 prospective clinical trials. Surgery 2023; 174:781-786. [PMID: 37541808 DOI: 10.1016/j.surg.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/14/2023] [Accepted: 06/18/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy is the gold standard for treating biliary colic in patients with gallstones, but post-cholecystectomy abdominal pain is commonly reported. This study investigates which symptoms are likely to persist and which may develop after a cholecystectomy. METHODS Patients from 2 previous prospective trials who underwent laparoscopic cholecystectomy for symptomatic cholecystolithiasis were included. Patients completed questionnaires on pain and gastrointestinal symptoms before surgery and at 6 months follow-up. The prevalence of persistent and new-onset abdominal symptoms was evaluated. RESULTS A total of 820 patients received cholecystectomy and were included, 75.4% female (n = 616/820) mean age 49.4 years (standard deviation 13.7). At baseline, 74.1% (n = 608/820) of patients met all criteria for biliary colic. Cholecystectomy successfully resolved biliary colic in 94.8% (n = 327/345) of patients, but 36.5% (n = 299/820) of patients reported persistent abdominal pain after 6 months of follow-up. The prevalence of most abdominal symptoms reduced significantly. Symptoms such as flatulence (17.8%, n = 146/820) or restricted eating (14.5%, n = 119/820) persisted most often. New-onset symptoms were frequent bowel movements (9.6%, n = 79/820), bowel urgency (8.5%, n = 70/820), and new-onset diarrhea (8.4%, 69/820). CONCLUSION Postcholecystectomy symptoms are mainly flatulence, frequent bowel movements, and restricted eating. Newly reported symptoms are mainly frequent bowel movements, bowel urgency, and diarrhea. The present findings give clinical guidance in informing, managing, and treating patients with symptoms after cholecystectomy.
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Affiliation(s)
- Floris M Thunnissen
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Cléo Baars
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rianne Arts
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | | | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Cornelis J H M van Laarhoven
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Marten A Lantinga
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centres Amsterdam, The Netherlands. https://twitter.com/PhilipReuver
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
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Latenstein CSS, Hannink G, van der Bilt JDW, Donkervoort SC, Eijsbouts QAJ, Heisterkamp J, Nieuwenhuijs VB, Schreinemakers JMJ, Wiering B, Boermeester MA, Drenth JPH, van Laarhoven CJHM, Dijkgraaf MGW, de Reuver PR. A Clinical Decision Tool for Selection of Patients With Symptomatic Cholelithiasis for Cholecystectomy Based on Reduction of Pain and a Pain-Free State Following Surgery. JAMA Surg 2021; 156:e213706. [PMID: 34379080 DOI: 10.1001/jamasurg.2021.3706] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance There is currently no consensus on the indication for cholecystectomy in patients with uncomplicated gallstone disease. Objective To report on the development and validation of a multivariable prediction model to better select patients for surgery. Design, Setting, and Participants This study evaluates data from 2 multicenter prospective trials (the previously published Scrutinizing (In)efficient Use of Cholecystectomy: A Randomized Trial Concerning Variation in Practice [SECURE] and the Standardized Work-up for Symptomatic Cholecystolithiasis [Success] trial) collected from the outpatient clinics of 25 Dutch hospitals between April 2014 and June 2019 and including 1561 patients with symptomatic uncomplicated cholelithiasis, defined as gallstone disease without signs of complicated cholelithiasis (ie, biliary pancreatitis, cholangitis, common bile duct stones or cholecystitis). Data were analyzed from January 2020 to June 2020. Exposures Patient characteristics, comorbidity, surgical outcomes, pain, and symptoms measured at baseline and at 6 months' follow-up. Main Outcomes and Measures A multivariable regression model to predict a pain-free state or a clinically relevant reduction in pain after surgery. Model performance was evaluated using calibration and discrimination. Results A total of 1561 patients were included (494 patients in 7 hospitals in the development cohort and 1067 patients in 24 hospitals in the validation cohort; 6 hospitals included patients in both cohorts). In the development cohort, 395 patients (80.0%) underwent cholecystectomy. After surgery, 225 patients (57.0%) reported that they were pain free and 295 (74.7%) reported a clinically relevant reduction in pain. A multivariable prediction model showed that increased age, no history of abdominal surgery, increased visual analog scale pain score at baseline, pain radiation to the back, pain reduction with simple analgesics, nausea, and no heartburn were independent predictors of clinically relevant pain reduction after cholecystectomy. After internal validation, good discrimination was found (C statistic, 0.80; 95% CI, 0.74-0.84) between patients with and without clinically relevant pain reduction. The model had very good overall calibration and minimal underestimation of the probability. External validation indicated a good discrimination between patients with and without clinically relevant pain reduction (C statistic, 0.74; 95% CI, 0.70-0.78) and fair calibration with some overestimation of probability by the model. Conclusions and Relevance The model validated in this study may help predict the probability of pain reduction after cholecystectomy and thus aid surgeons in deciding whether patients with uncomplicated cholelithiasis will benefit from cholecystectomy.
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Affiliation(s)
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | | | - Joos Heisterkamp
- Department of Surgery, Elisabeth-Tweesteden Ziekenhuis, Tilburg, the Netherlands
| | | | | | - Bastiaan Wiering
- Department of Surgery, Slingeland Ziekenhuis, Doetinchem, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Biostatistics and Bioinformatics, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
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Zhang J, Lu Q, Ren YF, Dong J, Mu YP, Lv Y, Zhang XF. Factors relevant to persistent upper abdominal pain after cholecystectomy. HPB (Oxford) 2017; 19:629-637. [PMID: 28495436 DOI: 10.1016/j.hpb.2017.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/12/2017] [Accepted: 04/10/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cholecystectomy is a routine procedure for treatment of upper abdominal pain (UAP) and other atypical symptoms associated with gallstones. UAP, however, persists in some cases postoperatively. The present study was to identify the risk factors relevant to persistent UAP after cholecystectomy. METHODS 1714 symptomatic patients undergoing cholecystectomy for gallstones were enrolled. All the patients were asked to complete a biliary symptom questionnaire. The risk factors for persistent postcholecystectomy UAP and features related to sustained relief of postcholecystectomy UAP were evaluated. RESULTS 172 (10%) patients complained UAP after cholecystectomy. In multivariate analysis, female gender, preoperative UAP occurring >24h before admission, and each episode of UAP >30min were independently associated with persistent postoperative UAP (all p < 0.05). 132 (76.7%) patients reported sustained relief of postcholecystectomy UAP, the causes of which remained unknown but were attributed to functional postcholecystectomy syndrome. Shorter duration of preoperative UAP (occurring within 24 h before admission), less frequency of postoperative UAP (≤1 episode per day) and administration of choleretic medications were independently associated with postoperative UAP relief (all p < 0.05). CONCLUSION Females with longer historical and more frequent preoperative UAP are more likely to develop postcholecystectomy UAP. Choleretic medications are effective in relieving postoperative UAP.
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Affiliation(s)
- Jing Zhang
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University Xi'an, Shaanxi Province, 710061, China; Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center Xi'an, Shaanxi Province, 710061, China
| | - Qiang Lu
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University Xi'an, Shaanxi Province, 710061, China; Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center Xi'an, Shaanxi Province, 710061, China
| | - Yi-Fan Ren
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University Xi'an, Shaanxi Province, 710061, China; Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center Xi'an, Shaanxi Province, 710061, China
| | - Jian Dong
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University Xi'an, Shaanxi Province, 710061, China; Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center Xi'an, Shaanxi Province, 710061, China
| | - Yi-Ping Mu
- Department of Medical Record, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, 710061, China
| | - Yi Lv
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University Xi'an, Shaanxi Province, 710061, China; Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center Xi'an, Shaanxi Province, 710061, China
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University Xi'an, Shaanxi Province, 710061, China; Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center Xi'an, Shaanxi Province, 710061, China.
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